Why Do Uterine Polyps Develop and Should They Be Removed?

Uterine polyps seldom cause symptoms but can occasionally become malignant tumors.

There are two types of uterine polyps: placental and endometrioid. Placental polyps are rare and typically occur after abortions or miscarriages. When discussing uterine polyps, the focus is usually on endometrial polyps, which will be the subject here.

What Are Endometrial Polyps and Their Types?

The uterus's inner lining is covered by the endometrium, where a fertilized egg implants and which sheds with menstrual bleeding if pregnancy does not occur.

Normally, the endometrium is smooth, but sometimes growths ranging from the size of a sesame seed to a golf ball or larger can appear. These are endometrial polyps. They contain connective tissue and blood vessels, so they do not shed during menstruation and can continue growing.

One or multiple polyps may develop in the uterus. They can vary in appearance: some are elongated on a thin stalk, hanging like a pear into the uterine cavity or protruding into the vagina, while others have a broad base, bulging as nodules.

Polyps also differ histologically. Some have a normal layered structure with healthy cells, while others show twisted vessels, disrupted tissue architecture, and cells that may become cancerous.

Polyps can appear at any age but are most common in women aged 40–50.

What Causes Uterine Polyps?

Researchers believe that elevated estrogen levels are the main cause of endometrial polyps. Excess estrogen in the blood is termed absolute hyperestrogenism, but relative hyperestrogenism—normal estrogen levels combined with insufficient progesterone—is more common, especially after age 40 when ovulation ceases and progesterone production drops.

Studies indicate that hyperestrogenism and thus polyps are more frequent with:

• Excess body weight. Estrogen is produced not only by the ovaries but also by fat tissue. While fat is minimal, hormonal balance remains intact; excessive fat disrupts it.
• High blood pressure, often linked to overweight women.
• Tamoxifen use. This medication treats breast cancer by blocking estrogen receptors in cancer cells, preventing tumor growth. However, estrogen remains in the bloodstream and may stimulate the endometrium.
• Hormone replacement therapy during postmenopause, which introduces estrogen into the body.

Chronic uterine inflammation can also lead to polyp formation due to abnormal endometrial cell division.

Risks Associated with Endometrial Polyps

Typically, endometrial polyps are benign, non-invasive growths that do not metastasize and have cells similar to the surrounding lining. However, complications may include:

• Malignant transformation. Approximately 5.6% of women with atypical endometrial polyps—characterized by immature cells, altered nuclei, and disorganized tissue layers—develop cancer.
• Chronic anemia. Polyps can cause uterine bleeding, and frequent bleeding lowers hemoglobin levels.
• Infertility. Polyps may block sperm passage to the fallopian tubes or prevent embryo implantation. Infertility is linked to polyps in 3.8–38.5% of cases.

Symptoms Indicating Uterine Polyps

Many polyps cause no symptoms and are found incidentally during examinations. However, symptoms warranting gynecological consultation include:

• Irregular menstrual cycles: variable days between periods, cycles longer than 35 days or shorter than 21 days.
• Spotting or heavy bleeding between periods.
• Postmenopausal bleeding.
• Significantly heavier menstruation requiring more sanitary products.
• Difficulty conceiving.

Seek immediate medical attention or emergency services if sanitary pads become saturated in under 2 hours, indicating severe uterine bleeding that can be life-threatening.

Diagnosing Endometrial Polyps

Polyps are rarely visible during a routine gynecological exam unless large and protruding through the cervix, necessitating specialized diagnostic methods:

• Transvaginal ultrasound performed on the 10th day of the menstrual cycle. It is straightforward but may miss polyps or confuse them with fibroids, requiring further tests.
• Doppler ultrasound highlights blood flow in vessels, helping identify arteries supplying the polyp.
• Sonohysterography involves injecting saline into the uterus during ultrasound, expanding the cavity to distinguish polyps from fibroids and detect small lesions by their movement in fluid.
• Hysteroscopy involves inserting a flexible camera tube into the uterus under anesthesia, allowing direct visualization, biopsy, and polyp removal during the procedure.

Histological examination of polyp tissue is essential to determine its structure and cancer risk.

Treatment Options for Uterine Polyps

Treatment varies: a gynecologist may remove the polyp, prescribe medication, or recommend observation. Some studies suggest that polyps smaller than 10 mm that cause no symptoms may resolve within a year under medical supervision.

Polyp Removal

Medical consensus on removing all endometrial polyps is not definitive. However, removal is advised for bleeding, pregnancy planning, or menstrual irregularities to restore normal cycles.

Removal methods include:

• Dilation and curettage (D&C): Under anesthesia, a metal loop scrapes the uterine lining, suitable for small polyps, with tissue sent for analysis.
• Hysteroscopic polypectomy: The preferred treatment, enabling direct visualization and precise removal with an electric loop, followed by cauterization of the base. Minor bleeding may persist for 1–2 days post-op.
• Hysterectomy: Reserved for polyps with malignant cells to prevent cancer progression and mortality.

Medication Therapy

Gynecologists may prescribe hormonal pills, injections, or intrauterine devices to reduce estrogen production or block its effect on the endometrium.

These treatments provide temporary relief; symptoms and polyp size decrease during therapy but return after cessation.

Medications are mainly used to delay surgery or reduce recurrence risk after polyp removal.

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